Fillable Form 22-0049 - Designate Mailing Request printable pdf download

Form

Designate Mailing Request

Property Owner

Current Utility Account # (first 9 digits)

Assessment Roll Number (21 digits)

Property Owner(s) Name (First, Last)

Telephone Number

Property Address (Street Number, Street Name, Suite/Unit Number, City/Town, Province, Postal Code)

Current Mailing Address (Street Number, Street Name, Suite/Unit Number, City/Town, Province, Postal Code)

Please mail my Utility Bill to:

Designate Name (First, Last)

Telephone Number

Mailing Address (Street Number, Street Name, Suite/

If this request reflects a change in designate, please

Unit Number, City/Town, Province, Postal Code)

indicate the effective date of the change (yyyy-mm-dd)

By signing this Utility Bill Designate Mailing Request, I authorize the City of Toronto to follow my expressed wishes

with regard to where and to whom my Utility Bill and notices are mailed. I further agree:

1. That I will, in all cases, remain solely responsible for a Utility Bill's payment, including any loss of discount and

other fees and charges added in relation to any collection effort.

2. That the person authorized to receive utility bills and notices is also appointed by me as my agent with respect to

making payments and granting the City access to the property for purposes relating to the provision of water,

sewer and solid waste management services.

3. That I will, at all times, provide the City with current contact information for the property's occupants.

4. That the City can cancel this Utility Bill Designate Mailing Request for any reason and at any time.

5. That if I am currently enrolled in the City's Pre-Authorized Utility Payment Program, I acknowledge my enrolment

will automatically expire when the approved Designate Mailing Request Form is entered in the City's records.

Property Owner(s) Signature

Print Name (First, Last)

Date

(yyyy-mm-dd)

Mailing Designate

You are receiving this request because the named property owner(s) wishes to have his or her Utility Bill mailed to

you and is appointing you their agent for the purpose of making payments and granting the City access to the

property for purposes relating to the provision of water, sewer and solid waste management services.

The named property owner(s) will provide the City with the following personal information: your name, mailing

address and telephone number in the section above.

If you consent to the provision of the above mentioned personal information (name, mailing address and telephone

number) the City requests that you sign below. Signing below will also signify your consent to the method of collection

of personal information outlined in this form. Please have this form returned to the City. I understand that an

administrative fee per Utility Bill will be charged for every bill sent to a designate.

Print Name (First, Last)

Signature

Date

(yyyy-mm-dd)

CLEAR

22-0049 2016-11

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Form 22-0049 - Designate Mailing Request

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